Written by: Dr. Thomas Hermann
The goal of dental care in correctional settings is to manage and treat oral diseases that can negatively affect inmates’ quality of life. We aim to improve and maintain oral health by providing basic dental care, including examinations, periodontal care, oral surgery, restorative treatments, and prosthetic services. The prevalence of dental disease, such as tooth decay and gum disease, is higher in inmate populations than in the general population, largely due to lifestyle choices and lack of adequate care prior to institutionalization. This results in high demand for dental services in inmate populations.
Dental teams in corrections attempt to utilize available resources to meet that need. Suffering from dental pain and infection makes incarcerated life difficult, and oral surgery procedures to remove infected teeth and manage infection are provided to mitigate this problem. Repairing compromised teeth with fillings helps maintain and restore patients’ ability to chew food and provide adequate nutrition to meet the body’s needs. Similarly, replacing missing teeth with partial and full dentures improves the ability to chew and to obtain nutrition. Not only does this improve physical health, but restoring a smile can also positively impact self-esteem. This can improve the ability to obtain employment and reintegrate into society after release from corrections.
PERIODONTAL DISEASE
Periodontal (gum) disease is among the most common diseases affecting humans. Risk factors for periodontal disease include poor oral hygiene, lack of professional dental treatment, age, and smoking tobacco. It is estimated that nearly half of Americans aged 30 and 70% over age 65 are affected by it. However, estimates for incarcerated patients suffering from this disease approach 95% of the total incarcerated population. Periodontal disease is a bacterial progressive inflammatory disease that, over time, destroys the connective tissues and bone surrounding the teeth. It is insidious and asymptomatic in the early stages. As the disease progresses, it eventually results in red, swollen, infected gum tissue, which bleeds easily. The gum tissue will recede from the teeth, creating pockets that harbor pathogens. Furthermore, the bone around the affected teeth is progressively lost, resulting in loose teeth, painful mastication, and often bad breath. In its early stages, the disease is reversible, but once it has progressed to advanced stages, it is irreversible. This makes it incurable, but it is manageable with proper care.
Beyond the oral tissues affected by the disease, research over the past 20 years has implicated periodontal disease in several systemic conditions, including bacterial pneumonia, diabetes mellitus, low birth weight, and cardiovascular disease. More than 500 species of complex microflora have been isolated in the infected periodontal environment. Transient bacteremia (bacteria present in the bloodstream) following dental procedures such as dental extraction, dental scaling, and periodontal treatment has been well documented. These are procedures commonly performed to meet the dental needs in the correctional environment. Periodontal disease, as stated above, is prevalent among inmate populations.
In advanced periodontal disease, compromised oral tissues harbor increased, prolonged bacterial populations and promote the breakdown of the oral environment’s natural defense mechanisms. Oral gingival tissue is highly vascularized and, when inflamed, can often facilitate bacteremia and systemic spread of proteins (cytokines) from periodontal plaques through the bloodstream to other organ systems. This has led to a growing understanding that periodontal disease may contribute to non-oral disease conditions. While a causal relationship between periodontal disease and other diseases has not been firmly established, ongoing research continues to suggest one. Treatment for periodontal disease may reduce morbidities of various diseases, which emphasizes the need for effective treatment in order to enhance the health of inmate populations. The disease entities most often associated with periodontal disease are discussed below.
CARDIOVASCULAR DISEASE
Incarcerated individuals are at a higher risk of complications from cardiovascular disease (CVD) than the general population. For incarcerated individuals, it is among the leading causes of death, at approximately 28% of mortalities. Risk factors for CVD include tobacco product use, smoking, high blood pressure (hypertension), high cholesterol (dyslipidemia), age, and stress. Inmate populations are particularly susceptible to these risk factors.
As early as the first decade of the 1900’s, Dr. Thomas Horder recognized that “oral sepsis” played a significant role in the development of infective heart disease for high-risk individuals. Studies have investigated possible interactions concerning various conditions, namely endocarditis, coronary arterial disease (CAD), hypertension, and atrial fibrillation. Research has shown higher rates of hypertension in periodontal patients compared to those without periodontal compromise. Periodontal patients have a 31% higher risk for atrial fibrillation, perhaps due to the effects of chronic infection and inflammation.
The chronic inflammatory nature of periodontal disease has, over the years, been implicated as a possible aggravating factor in the development of heart disease. Numerous studies have investigated the possible mechanisms of such a relationship. For example, they have shown that bacterial strains present in periodontal disease, such as Streptococcus sanguinis and Porphyromonas gingivalis, can promote platelet aggregation and the formation of blood clots (thrombi). Furthermore, research has found such bacteria in 42% of arterial plaques from patients with severe periodontal disease. Enzymes produced by these bacteria have also been shown to contribute to intravascular clot formation. Other cellular-level inflammatory products from periodontal disease have been shown to affect the production of liver enzymes and have been connected to the progression of heart disease.
As the incarcerated population is at risk for cardiovascular disease and has a higher rate of periodontal disease, it is clear that appropriate dental treatment is necessary to achieve and maintain overall health. For those with high-risk cardiovascular disease co-morbidities, such as congenital heart defects, prosthetic heart valves, and heart transplants, the American Dental Association recommends antibiotic prophylactic coverage before dental treatment for patients.
DIABETES MELLITUS
Diabetes is a chronic condition that results in high blood sugar levels (hyperglycemia) and metabolic abnormalities, involving long-term complications for the eyes, kidneys, and periodontal tissues. There is speculation that tooth loss can lead patients toward a softer, more easily accessible diet (via the commissary). Typically, this results in an unhealthy diet, which has been implicated as a risk for obesity, diabetes, and cardiovascular disease.
Diabetes and periodontal disease appear to have a two-way relationship, in that type 2 diabetes is a risk factor for periodontal disease and severe periodontal disease can exacerbate the effects of diabetes. Consequently, diabetic-related tissue destruction can result in a more severe periodontal condition. The presence of severe periodontal disease seems to make it more difficult to control blood sugars and keep diabetes under control. Randomized trials indicate that periodontal treatment, such as scaling and root planing, can help control blood sugar levels and contribute to improvements in diabetes management. Given the interaction between diabetes and periodontal disease, it is essential that dental teams provide periodontal treatment to patients diagnosed with diabetes. The effects of this treatment may well extend beyond improved oral condition to a positive impact on diabetic control for inmate populations.
BACTERIAL PNEUMONIA/RESPIRATORY CONDITIONS
Incarcerated populations are more likely to suffer from respiratory illness than the general population. Smoking history, congregate settings, and recirculated ventilation contribute to the increased risk. Multiple studies have investigated the possible connection between the pathogenic bacteria seen in periodontal disease and episodes of bacterial pneumonia, and a relationship has been demonstrated between poor oral hygiene and bacterial pneumonia.
One mechanism proposed for bacterial pneumonia is aspiration of the pathogens common to periodontal disease. Patients with signs of definite aspiration pneumonia have been shown to be over three times more likely to have periodontal disease. One way the dental team can help mitigate this potential risk is to continue providing sound periodontal therapy and promoting improved oral hygiene among correctional inmate patients.
CONCLUSION
A plethora of evidence has accumulated over the years suggesting that chronic infection from uncontrolled periodontal disease can have an effect on the progression and status of a number of non-oral diseases, such as cardiovascular disease, diabetes mellitus, and bacterial pneumonia. Research continues to investigate this possibility; however, it has become clear that uncontrolled periodontal disease can exacerbate the course of various conditions. The mission of any dental staff member is to promote the patient’s overall health, and treating periodontal disease is a key component of that health, so it is imperative that Medical Staff and Dental Staff maintain open communication and collaborate in caring for their patients.
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